Adherence to antimicrobial prophylaxis guidelines in cardiac implantable electronic device procedures in two Australian teaching hospitals
Monique Almonte A G , Taylor Huston A H , Sok Ling Yee A I , Roya Karimaei A J , Adam Hort
B , Matthew Rawlins B , Jason Seet C , Zachiah Nizich C , Duncan McLellan D , Paul Stobie E , Petra Czarniak A F and Leanne Chalmers A F K
A School of Pharmacy and Biomedical Sciences, Curtin University, Bentley, WA, Australia. Email: moniquealmonte1@gmail.com; hustonium93@gmail.com; sokling.yee@gmail.com; karimaeiroya@gmail.com
B Pharmacy Department, Fiona Stanley Hospital, South Metropolitan Health Service, Murdoch, WA, Australia. Email: adam.hort@health.wa.gov.au; Matthew.Rawlins@health.wa.gov.au
C Pharmacy Department, Sir Charles Gairdner Hospital, North Metropolitan Health Service, Nedlands, WA, Australia. Email: jason.seet@health.wa.gov.au; Zachiah.Nizich@health.wa.gov.au
D Infectious Diseases Department, Fiona Stanley Hospital, South Metropolitan Health Service, Murdoch, WA, Australia. Email: Duncan.McLellan@health.wa.gov.au
E Department of Cardiovascular Medicine, North Metropolitan Health Service, Nedlands, WA, Australia. Email: paul.stobie@health.wa.gov.au
F Present address: Curtin Medical School, Curtin University, Bentley, WA, Australia. Email: P.Czarniak@curtin.edu.au
G Present address: Northlands Pharmacy, Balcatta, WA, Australia.
H Present address: TerryWhite Chemmart Leeming, Leeming, WA, Australia.
I Present address: Pharmacy Alliance, Albany, WA, Australia.
J Present address: Pharmacy 777 Lynwood, Lynwood, WA, Australia.
K Corresponding author. Email: leanne.chalmers@curtin.edu.au
Australian Health Review 45(6) 761-770 https://doi.org/10.1071/AH21046
Submitted: 8 February 2021 Accepted: 25 May 2021 Published: 2 September 2021
Abstract
Objective This study investigated antibiotic prophylaxis (AP) guideline adherence and the cardiac implantable electronic device (CIED) infection rate in two major Australian public teaching hospitals.
Methods In a retrospective observational study, the medical records of patients who underwent CIED procedures between January and December 2017 were reviewed (Hospital A, n = 400 procedures; Hospital B, n = 198 procedures). Adherence to AP guidelines was assessed regarding drug, dose, timing, route and frequency. Infection was identified using follow-up documentation.
Results AP was administered in 582 of 598 procedures (97.3%). Full guideline adherence was observed in 33.9% of procedures (203/598) and differed significantly between Hospitals A and B (47.3% vs 7.1%, respectively; P < 0.001). Common reasons for non-adherence were the timing of administration (42.3% vs 60.6% non-adherent in Hospitals A and B, respectively; P < 0.001) and repeat dosing (19.3% vs 78.8% non-adherent in Hospitals A and B, respectively; P < 0.001). Twenty infections were identified over 626.6 patient-years of follow-up (mean (±s.d.) follow-up 1.0 ± 0.3 years). The infection rate was 3.19 per 100 patient-years (P = 0.99 between hospitals). Two devices were removed due to infection; no patients died from CIED infection.
Conclusions Although the rate of serious CIED infection was low, there was evidence of highly variable and suboptimal antibiotic use, and potential overuse of AP.
What is known about the topic? Previous Australian studies have revealed high rates of inappropriate surgical AP. CIED infections are potentially life threatening, but can be avoided through effective use of AP. However, prolonged durations of AP in this setting may also result in complications, including Clostridioides difficile infection.
What does this paper add? This study, the first to our knowledge to focus specifically on adherence to Australian guidelines for AP in CIED procedures, highlighted several common issues between AP in this setting and surgical and procedural AP more broadly. ‘Early’ and ‘late’ dose administration and extended post-procedural AP were common. Only 34% of prescriptions fully adhered to the guidelines; practices varied significantly between the two hospitals.
What are the implications for practitioners? There is a clear need for institution-specific antimicrobial stewardship strategies to optimise AP in CIED procedures, aligned with the Antimicrobial Stewardship Clinical Care Standard. Patients are being placed at potentially avoidable risk of both complications of extended durations of AP and CIED infection, although the rate of serious CIED infection was low. A standardised approach to surveillance of CIED infections and prospective multisite audits of AP in CIED procedures using a validated tool, such as the Surgical National Antimicrobial Prescribing Survey, are recommended to better inform evidence-based practice. Potential strategies to optimise guideline adherence include prescribing support in patients with immediate penicillin hypersensitivity or methicillin-resistant Staphylococcus aureus colonisation, optimising the in-patient location of drug administration to promote timely dosing, limiting inappropriate post-procedural prophylaxis and routine S. aureus screening and decolonisation.
Keywords: antibiotic prophylaxis, cardiac implantable electronic device, guideline adherence, prescribing practices, surgical site infection.
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